440 The ABC of ommunity emergeny are 14 ASSESSMENT AND MANAGEMENT OF NEUROLOGICAL PROBLEMS (1) J T Gray, C M Gavin THE T Emerg Med J 2005; 22:440 445. doi: 10.1136/emj.2005.026658 he assessment and management of neurologial symptoms presents a partiular hallenge in the ommunity, as the differential diagnosis may be wide and inlude potentially serious onditions. Whilst the pratitioner may ommonly enounter onditions suh as stroke and the fitting patient, all patients will require areful assessment to avoid the pitfalls of missing a serious underlying diagnosis. Headahe presents a partiular diagnosti diffiulty where the ause may range from the benign, to the life-threatening subarahnoid. Some neurologial symptoms may be non-speifi but indiate the possibility of rare onditions requiring urgent investigation and treatment. This first artile will over the primary survey positive patient inluding the unonsious patient, the fitting patient, and those patients presenting with headahe as their main symptom. The seond artile will over frequently enountered neurologial symptoms and signs to enable the pratitioner to develop a safe and omprehensive system to deide whih patients need immediate treatment and/or referral and whih may safely be treated at home. PRIMARY SURVEY POSITIVE PATIENT All patients should be assessed aording to ABC priniples in order to identify any immediately life-threatening onditions. Box 1 Primary survey If any observations below present treat immediately and transfer to hospital Airway Obstrution Respiratory rate,10 or.29 per minute O2 sats,93% Pulse,50 or.120 Systoli BP,90 mmhg GCS,12 Neurologial onditions an be immediately life threatening by ausing an ABC problem: Airway obstrution/ompromise loss of protetive airway reflexes due to oma. Breathing diffiulty/inadequay apnoea due to onditions affeting the respiratory entre for example, brainstem stroke, intraerebral ; respiratory musle weakness for example, Guillain Barre, myasthenia gravis Cirulatory ompromise septi shok seondary to CNS infetion, hypertension, and bradyardia in patients at imminent risk of oning. The two main ategories of immediately primary survey positive patients seen by the ommunity pratitioner are the unonsious patient and the fitting patient. THE UNCONSCIOUS PATIENT The unonsious patient is traditionally defined as having a GCS of 8 or less. It is very diffiult to make an aurate neurologial assessment of these patients and they will require a full hospital assessment. Arrange a 999 paramedi ambulane to transfer these patients to hospital. Priorities in management will follow ABC priniples well desribed elsewhere in this series. See end of artile for authors affiliations Correspondene to: Dr Carole Gavin, Consultant in Emergeny Mediine, Hope Hospital, Salford, M6 8HD; arole.gavin@srht.nhs.uk Airway Ensure an adequate airway using routine airway opening manoeuvres augmented by an oropharyngeal or nasopharyngal airway as appropriate. If there is any possibility of trauma then use a jaw thrust not a hin-lift, head-tilt. Give oxygen (15 litres via a non-rebreathing mask). Breathing Chek the patient is breathing adequately. Hypoventilation will require bag/valve mask assistane. Chek oxygen saturation by pulse oximetry. www.emjonline.om
THE ABC OF COMMUNITY EMERGENCY CARE Cirulation Chek the pulse and if possible the blood pressure. Establish in vitro aess if possible. Disability Measure the Glasgow Coma Sore (GCS). If there is no response to pain hek the tone in the limbs. When ommuniating the GCS sore to seondary are it an be very usefully broken down into its separate omponents to give a lear impression of neurologial status (Box 2). Chek pupil size and reation. A unilaterally dilated pupil may indiate an intraerebral heamatoma, pinpoint pupils may indiate a pontine stroke or raise the suspiion of poisoning for example, opiates. Bilateral dilated pupils may suggest poisoning with benzodiazepines or triyli antidepressants. 441 Box 2 Glasgow Coma Sore Maximum Sore = 15 Minimum Sore = 3 A patient is defined as unonsious with a sore of 8 or less Eye response 4 Open spontaneously 3 Open to ommand 2 Open to pain 1 No eye opening Verbal response 5 Fluent and orientated 4 Confused speeh 3 Inappropriate words 2 Inomprehensible sounds 1 No verbal response Motor response 6 Obeys ommands 5 Loalising pain 4 Withdraws from pain 3 Flexion to pain 2 Extension to pain 1 No motor response In addition to ABCD, E (exposure) and G (gluose) should be assessed to searh for lues as to the possible underlying ause eg. a rash may suggest meningitis or septiaemia (fig 1), punture marks may indiate a drug overdose (fig 2). History Try to gain as muh information as possible to suggest possible auses of unonsiousness. Obtain a history of the episode from Figure 2 Needletrak marks in intravenous drug user. any witnesses; ask if they know of any previous medial history, presribed mediations, or history of illiit drug use. The main auses of unonsiousness are summarised in table 1. Table 1 Cause Common auses of unonsiousness Clinial lues Vasular Intraerebral bleed History of preeding sudden onset headahe Subarahnoid Foal neurologial signs Stroke Metaboli Hypoglyaemia History of diabetes mellitus Severe hyperglyaemia Always hek the gluose (hyperosmolar non ketoti oma) Severe hyponatraemia Poisoning Opiates History of illiit drug use, aloholism or mental health problems Triylis Presene of empty pill bottles Benzodiazepines Pin-point pupils (opiates) Carbon monoxide (aidental or deliberate) Dilated pupils (triylis or benzodiazepines) Alohol Head injury History of falls Salp laeration, bruising or swelling Periorbital bruising Epilepsy Previous history of fits Status epileptius (non-onvulsive) Postital Infetion History of prodromal illness Meningitis Rash Enephalitis Pyrexia Sepsis Signs of septi shok (peripheral vasodilatation, tahyardia, hypotension) Hypothermia Temperature,35 C Figure 1 Purpuri rash in meningooal septiaemia. www.emjonline.om
GRAY, GAVIN Suspeted meningitis Table 2 Cause of fit Causes of fits Clinial lues 442 RING 999 stating suspeted meningitis Give oxygen if available Give Benzylpeniillin IV/IO immediately. If unable, then give IM Infant 300 mg Child 1 9 600 mg Over 10 years 1200 mg Figure 3 If signs of irulatory ollapse, then administer IV fluids and manage as septi shok Treatment of suspeted meningitis in the ommunity. Treatment Treatment will be mainly supportive pending transfer to hospital. If a treatable ause is identified then this should be treated as soon as possible in order to minimise seondary brain injury. Hypoglyaemia should be treated immediately by either 10% gluose in vitro or intramusularly gluagon administration. If there is strong suspiion that a patient may have taken an overdose of opiates and they have respiratory ompromise, then intravenous or intramusularly naloxone should be administered. If meningooal disease is suspeted then antibiotis should be given immediately (fig 3). THE FITTING PATIENT The fitting patient an present a signifiant hallenge to the pratitioner. Attempts should be made to stop the fitting and assess further as required. The National Institute for Clinial Exellene (NICE) guidelines should be followed (Box 3). 1 Box 3 NICE Guidane on fit management If onvulsive seizures lasting 5 minutes or longer or three or more seizures in an hour Seure the airway Assess respiratory and ardia funtion Give retal diazepam in most ases with bual midazolam an alternative Call emergeny servies if required by the situation or the response to treatment, and partiularly if Seizures develop into status epileptius There is a high risk of reurrene This is the first episode There may be diffiulties monitoring the persons ondition Airway management Airway management in the fitting patient an be problemati due to jaw spasm, and a nasopharyngeal airway an be very useful if the fit is protrated with worsening airway ompromise. Give oxygen and sution away any exess seretions. If possible plae the patient on their side. Most fits Epilepsy Conurrent illness eg, infetion Changes in mediation Non-ompliane with mediation CNS infetion Meningitis Enephalitis Head injury Vasular Stroke (new or old) Subarahnoid Intraerebral Metaboli Hypoglyaemia Hyponatraemia Hepati enephalopathy Poisoning Alohol Triyli antidepressants Mefenami aid Misellaneous Alohol withdrawal Elampsia Malignant hypertension Intraerebral tumour or metastases Previous history of epilepsy History of reent illness/ headahe Rash History of reent trauma Evidene of salp bruising, swelling et. May be foal neurologial signs Always hek blood gluose Patient jaundied?smell of alohol history of mental illness empty tablet bottles Known aloholi who doesn t smell of alohol Patient pregnant Diastoli BP.110 mmhg History of malignany will stop spontaneously. Do not forget to hek the blood gluose. If the fit is prolonged or reurrent, drug treatment may be required. Retal diazepam is effetive but it may be diffiult to administer by a pratitioner with no help. Intravenous diazemuls, lorazepam, or bual midazolam are alternatives that may be used in aordane with loal protools. Following essation of the fit assess the patient for any obvious preipitating ause and for any injuries they may have sustained during the ourse of the fit. Common auses of fits are summarised in table 2. In patients with known epilepsy, fits may be preipitated by onurrent illness or hanges in their mediation. Injuries may inlude head and faial trauma, fratures, and burns. Rarely patients may sustain a posterior shoulder disloation therefore shoulder movement should be heked. If the patient is a known epilepti, has a single fit and has ompletely reovered with normal vital signs and normal neurologial examination, they may be safely left at home as long as there is family or arer support. If there is no previous history of fits, if the fit was unusual in any way, if there are abnormal examination findings or if there is onern about a possible preipitating ause, then the patient should be transferred to hospital for a full assessment. Febrile seizures A febrile seizure is any seizure ourring in an infant or young hild (6 months to 5 years old) in onjuntion with a fever or history a reent fever and without evidene of a previous febrile seizure or an underlying ause suh as neurologial disease or CNS infetion. They are the most ommon seizures seen in the paediatri population in the prehospital setting, ourring in 2 5% of all hildren between the ages of 6 months and 5 years, therefore it is important that pratitioners are familiar with the priniples of their evaluation and management. 2 Febrile seizures generally have www.emjonline.om
THE ABC OF COMMUNITY EMERGENCY CARE a benign prognosis, however, dealing with these ases may be diffiult as the parents are often upset and frightened by the seizure and require a alm, reassuring approah by the pratitioner. The majority of these patients will have stopped fitting on arrival of assistane and most patients will only require minimal airway support during the post ital period. Chek oxygen saturations and irulatory status. Do not forget to hek the blood gluose. It is important to try and obtain a history to establish whether there may be a serious underlying ause suh as CNS infetion or trauma, and whether there is any history of previous seizures or neurologial onditions. Clinial examination should be foused towards signs related to infetion for example, rash or evidene of foal neurologial abnormalities, whih may suggest more sinister pathology. In the ase of a first seizure, if the seizure is prolonged or reurs within a 24 hour period or if there are abnormal linial findings, the hild should be transferred to hospital for a full assessment. If there is a history of previous febrile seizures and the parents are happy and onfident to manage the patient at home they may be disharged. Febrile seizures may reur in around 25% 30% of patients at 2 years therefore it is important that parents are given advie after any episode (Box 4). 2 Box 4 Advie to parents following febrile seizures Febrile seizures our in 2 5% of hildren aged 6 months to 5 years. They may appear frightening to observers but are generally harmless Simple febrile seizures often our only one in the first 24 hours of a febrile illness. If the seizure reurs your hild should be re-evaluated. A febrile seizure may manifest as body stiffening, twithing of the fae or limbs, eye rolling, jerking of the arms or legs, staring or loss of onsiousness. They generally last,1 minute but may last up to 15 minutes Your hild might appear not to be breathing and the skin olour may beome darker. If so, all 999 and lay the hild on the floor on his or her bak. DO NOT plae anything in the hild s mouth. Febrile seizures do not ause brain damage or paralysis Febrile seizures tend to run in families Febrile seizures an reur with subsequent febrile illnesses. Whilst paraetamol or ibuprofen may be used to try and derease the temperature these have not been shown to prevent febrile seizures. Table 3 Important fators in the history of a headahe Fators to onsider Signifiane Possible diagnosis Mode of onset Sudden onset, maximal severity,15 minutes Aute onset inreasing in severity Frequeny and duration Subarahnoid Meningitis, enephalitis, glauoma Subaute onset Temporal arteritis Expanding intraranial pathology hroni Important to distinguish types of reurrent headahe Site and radiation Oipital radiating to nek Unilateral Previous headahe history/hange from usual pattern Worse headahe ever Previous history, no hange Venous sinus thrombosis CO poisoning Hypertension Tension headahe Primary headahe syndromes: migraine luster headahe tension headahe trigeminal neuralgia Subarahnoid Migraine, trigeminal neuralgia Subarahnoid Primary headahe syndromes Time of onset Worse on waking Raised intraranial pressure Assoiated features Aggravating/ preipitating fators Vomiting SAH, meningitis, glauoma Nek stiffness/ SAH, meningitis Photophobia Fever CNS or ENT infetion Other neurologial symptoms Proximal weakness/ jaw laudiation Visual/olfatory aura Intraerebral, stroke Temporal arteritis Migraine q by head movement, oughing, straining Raised intraranial pressure triggers eg. heese, Migraine hoolate, menstruation Resolves with simple Unlikely sinister ause analgesia Family history Subarahnoid History of reent trauma Subarahnoid Subdural Post-onussion headahe Drug history Warfarin Intraerebral 443 HEADACHE THE PRIMARY SURVEY POSITIVE PATIENT A few patients will have obvious serious pathology on ABC evaluation. Any redution in GCS, aute onfusion, foal neurologial signs, or petehial rash indiates the need for urgent transfer to hospital. Supportive treatment should be provided as desribed elsewhere. Most patients, however, will not have any obvious signs of an immediately life-threatening problem. It is vital that these patients are assessed systematially in order to detet the small proportion of patients with serious pathology. The assessment of a patient with headahe an be diffiult for the most experiened liniian. Probably the most important fator in headahe assessment is the history and time should be spent in speifially eliiting features of the history that may be red flags mandating referral to hospital for further investigation and management. Important fators to onsider in the history of a headahe are summarised in table 3. Tip Sudden onset headahe with maximal severity,15 minutes is a subarahnoid until proven otherwise. www.emjonline.om
GRAY, GAVIN 444 Examination Examination of a patient with headahe should inlude a omplete systems examination as well as a thorough neurologial examination. Numerous non-neurologial disorders and onditions affeting the eyes, ear, nose, and throat may ause a headahe therefore the examination must inlude assessment of all the following: Consious level and mental state examination Drowsiness or onfusion all suggest intraranial pathology or infetion. Suh patients should be referred to hospital for a full assessment. Speeh This an easily be assessed whilst taking the history from the patient. Any evidene of slurred speeh (dysarthria), or diffiulty in word finding (dysphasia) suggests the patient may have had a stroke. Skull The skull should be palpated for any areas of tenderness or swelling and inspeted for bruising. Tenderness over the temporal area may suggest temporal arteritis and these patients must be referred for an urgent ESR. Nek pain/stiffness Nek stiffness may indiate meningeal irritation due to the presene of blood or infetion. Ask the patient to put their hin on their hest to see if this inreases pain. Kernigs and Brudzinskis sign are useful tests for evidene of meningism. Eyes Chek pupil reation at the same time heking for any photophobia. Chek for any restrition of eye movement (opthalmoplegia) or diplopia (ranial nerves III, IV, VI) and nystagmus. Chek visual auity and if possible examine the fundi. Rarely serious eye problems suh as glauoma may present with severe headahe. There will usually be abnormal eye signs inluding a red eye, loudy ornea, irregular middilated pupil and redued visual auity (fig 4). If there is any suggestion of glauoma the patient must be referred immediately for an ophthalmology assessment. ENT Examine the ears and throat for any evidene of infetion that may produe headahe. Pain on perussion over the sinuses may indiate sinusitis. General neurologial examination A full neurologial examination should be performed as summarised in Box 6. Brudzinski s sign Passive flexion of the nek indues involuntary hip flexion Kernig s sign With patient supine, flex hip to 90 with knee. When knee is extended, pain is produed in the bak of the nek. Figure 4 Aute glauoma. Systems examination Reord vital signs, in partiular temperature and blood pressure. Malignant hypertension may present with headahe and requires urgent treatment in hospital. Management plan Following a areful history and examination the pratitioner should be able to formulate a differential diagnosis and management plan. All headahes of aute, severe onset require immediate assessment in seondary are in order not to miss subarahnoid haemorrage. Any headahe assoiated with the red flags highlighted in table 3 or abnormal examination findings suggesting a possible serious ause should also be referred. If meningitis is suspeted then the patient should be treated with benzylpeniillin or a 3 rd generation ephalosporin. This should be given intravenously if possible although the intramusular route may be used if intravenous aess annot be seured (fig 3). Headahes of subaute or hroni onset, that are not assoiated with any red flags or abnormal neurologial findings will need further assessment, however, it may be more appropriate to refer these patients to their general pratitioner for assessment and outpatient referral if neessary. If patients are disharged they should be advised that if they develop any new features suh as vomiting, visual disturbane or other neurologial symptoms then they should seek urgent re-assessment. Beware the patient.60 years old with headahe of several weeks duration who may not have any abnormal physial findings but who may have temporal arteritis, whih untreated may lead to blindness. An urgent blood test for ESR will aid in this diagnosis. If the history and examination suggest a primary headahe syndrome suh as migraine then the patient may be treated in the ommunity. However, this diagnosis should only be made without further assessment if the patient has a previous history of migraine that fulfils the diagnosti riteria of the International Headahe Soiety (Box 7). 3 Migraine is best treated by a ombination of anti-inflammatory mediation (for example, dilofena) and an antiemeti (for example, metolopramide). Alternatively a 5HT agonist suh as sumatriptan may be given but remember this is ontraindiated in patients.65 years old or if there is a history of ishaemi heart disease or unontrolled hypertension. The diagnosis of tension headahe may be suggested by a hroni history of bilateral pressing or tight pain with no systemi disturbane or abnormal neurologial symptoms or www.emjonline.om
THE ABC OF COMMUNITY EMERGENCY CARE Box 6 General neurologial examination Signs of meningeal irritation Photophobia Nek stiffness Kernigs sign Higher mental funtion GCS Mental state examination Cranial nerves II visual auity and fields III, IV, VI eye movements V jaw power and fae sensation VII faial movements VIII hearing IX palate movements, swallowing XI shrugging shoulders XII tongue movement Limbs Power Tone Reflexes Sensation Co-ordination Balane and gait signs that get worse as the day progresses. It may be assoiated with a history of depression or mediation misuse. Analgesis are unhelpful if the headahe is hroni. This diagnosis should not be made until all other auses of headahe have been exluded by a thorough medial assessment and appropriate investigations. Patients omplaining of a headahe shortly after a head injury may be managed at home if they are fully alert and orientated and have a normal neurologial examination. They should be advised to seek medial attention if they have any of the following symptoms: vomiting inreased drowsiness or unonsiousness severe or worsening headahe double vision severe irritability or major hange in behaviour fitting Any patient who has suffered a signifiant loss of onsiousness or amnesia should be assessed in hospital as they may require a CT brain in aordane with the NICE head injury guidelines. 4 A patient omplaining of inreasing headahe days or even weeks after a head injury, partiularly if assoiated with other neurologial symptoms or signs may have a subdural haematoma and should be referred for assessment. Box 7 International Headahe Soiety diagnosti riteria for migraine Lasts 4 72 hours At least 2 of: unilateral loation, pulsating quality, moderate to severe intensity, aggravation by routine physial ativity At least 1 of: nausea/vomiting, photophobia, phonophobia At least 5 attaks fulfilling the above History and neurologial examination do not suggest underlying organi pathology. Pitfall Beware diagnosing migraine if the attak has lasted longer than 72 hours or if there has been inomplete resolution between attaks. Similarly, if the patient says this is the worst episode they have ever had or if it is different from their usual headahe pattern they will warrant hospital assessment. SUMMARY Neurologial emergenies are seen relatively ommon by the ommunity pratitioner and require areful assessment in order to identify potential serious pathology. Headahe presents a partiular diagnosti hallenge and a good history and examination is vital to avoid missing potentially life-threatening onditions suh as subarahnoid. This artile aims to provide a system to guide assessment and management, however, it is lear that in most ases patients will require seondary are assessment. Neurologial onditions are extremely frightening for both patients and arers who often fear they may be having a stroke or brain tumour, therefore reassurane and support is a ruial part of the primary are professionals role.... Authors affiliations J T Gray, C M Gavin, Hope Hospital, Salford, UK Competing interests: none delared REFERENCES 1 National Institute for Clinial Exellene 2004. The epilepsies: diagnosis and management of the epilepsies in adults in primary and seondary are. ISBN: 1-84257-806-5. (http://www.nie.org.uk). 2 Warden CR, Zibulewsky J, Mae S, et al. Evaluation and Management of Febrile Seizures in the Out-of-Hospital and Emergeny Department Settings. Ann Emerg Med 2003;1:215 222. 3 Oleson J, Lipton RB. Migraine lassifiation and diagnosis. International Headahe Soiety Criteria. Neurology 1994;44:S6 10. 4 National Institute for Clinial Exellene 2003. Head Injury: Triage, assessment, investigation and early management of head injury in infants, hildren and adults. ISBN 1-84257-306-3 (http://www.nie.org.uk). 445 www.emjonline.om